mhealth: Strengthening Health Initiatives through the Use of Mobile Technologies in state of Bihar, India

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1 22 nd June, 2016 mhealth: Strengthening Health Initiatives through the Use of Mobile Technologies in state of Bihar, India Dr. Hemant Shah, CARE AIDF Asia Summit

2 Bihar is one the most flood-prone states in India Bihar is India's most flood-prone State, with 76% of the population in the north Bihar living under the recurring threat of flood devastation 16.5% of the total flood affected area in India is located in Bihar while 22.1% of the flood affected population in India lives in Bihar. About 68,800 square kilometres out of total geographical area of 94,160 square kilometres comprising 73.06% is prone to floods There are 8 major rivers in Bihar which flow through Bihar and end up in Ganges Ghaghra Gandak Budhi Gandak Bagmati Kamala Bhutahi Balan Kosi Mahananda An average of 21 of the 38 districts in Bihar are affected by floods every year Source: 2

3 Mobile and TV penetration in Bihar Mobile Penetration TV Penetration Bihar is among the frontrunners in the country when it comes to penetration of cellphones in villages per cent of the rural population in Bihar uses cellphone, whereas the national average for the same stands at per cent The television ownership % ( as per census 2011) stands at 14.5% as compared to an all India average of 47.2%. Bihar has one of the lowest TV ownership % in India Such a high level of mobile phone penetration in villages of Bihar is despite the fact that per cent of the total rural population in the state is illiterate According to Telecom Regulatory Authority of India (TRAI), Bihar had nearly million wireless subscribers and 347,309 wire-line subscribers as of May 2015 At million, Bihar had the fifth largest wireless subscriber base among all the Indian states as of May As of , the state had 1,238 telephone exchanges. Source: TRAI, NSSO, WPWRF, Census

4 mhealth solution for Continuum of Care Services (CCS) was piloted as part of CARE s work in Bihar, India Background Since 2010, CARE has been implementing a large project for reducing maternal and child mortality, malnourishment and fertility rates in Bihar, India with financial support of Bill and Melinda Gates Foundation. As a part of this project, CARE had conceptualized an mhealth innovation in 2012 to improve service delivery by Community Health Workers (CHWs) to all pregnant women, mothers and newborns across 1000-day window of opportunity Objective To transition from manual records kept by CHWs across several hand-written registers, to electronic formats, thereby improving the frequency and quality of interactions between beneficiaries and Community Health Workers (CHWs) Methodology and Assessment Randomized Controlled Trial (RCT) was adopted to assess effect of the CCS mhealth innovation over and above other interventions with CHW. The randomized control trial was designed (with help of an external evaluation partner) and implemented, to assess whether the ICT tool would lead to improved outcomes. All CHWs, both in treatment and control, received trainings on conducting home visits and on messages to communicate with mothers. For robust measurement, two-year implementation was done with large number of CHWs. Reported results are from a two year follow-up. 4

5 Geographical spread and scale of pilot Saharsa Innovation Blocks 1. SONBARSA 2. SAUR BAZAR 3. KAHARA 4. SATTAR KATAYA Saharsa district lies along the Koshi river belt, and is highly susceptible to floods is one of the more disaster-prone areas in Bihar Bhabua Buxar Rohtas West Champaran Gopalganj Siwan Bhojpur Arwal East Champaran Saran Patna Sheohar Muzaffarpur Vaishali Nalanda Jehanabad Sitamarhi Samastipur Madhubani Darbhanga Begusarai Lakhisarai Saharsa Khagaria Munger Supaul Bhagalpur Araria Purnia Katihar Kishanganj Saharsa District Profile (all 4 blocks) Total # of Subcentre 70 # Treatment Subcentre 35 # Population Covered 3,34,470 # ASHA 240 # AWW 272 # ANM 45 # Lady Supervisors 12 Aurangabad Gaya Nawada Jamui Banka # CHWs, Supervisors 569 5

6 At it s core, this solution aimed at facilitating tracking of all events related to Maternal Health, Newborn Health, Child Health, Family planning and Nutrition Continuum of Care Services (CCS) across the 1000 day window of opportunity Area Areas of impact envisaged Change envisaged CHW-Beneficiary Questionnaire based interaction interaction Timely contact with objectivity Audio and video based content Supervisory Review Job-aids and Tools Supportive supervision Availability of real time data Simplified tools with easy data entry options Questions we wanted to address Is mobile technology usable and effective in the hands of AWW and ASHA during continuum of care? Can we establish the use of mobile technology as job-aids for AWW and ASHAs Frontline Workers (CHWs) and help improve Service Delivery? Can real-time data help effective Supportive Supervision? MIS & reporting Counselling job-aids (context-specific audio/ video clips) Due list generator Simple-to-use and saves time Date arithmetic tools (EDD and Referral) Real time data visibility for decentralized decision making 6

7 Key modules of mhealth solution Name-based tracking Registration (Pregnant Woman, Children upto 6 years) Services (antenatal care, postnatal care, exclusive breast feeding and initiation of complementary feeding, immunization, family planning) Events (birth, death, migration) Complications & High Risk Pregnancy Tracking Growth Monitoring up to 6 years of child s age as per WHO standards Home visit scheduler with guided questions in a structural manner to cover 19 necessary home visits in the continuum of care (-9 to +24 months) Due List (on-demand mobile based) Nutritional Components(THR, Spot Feeding & Preschool Activities) Tools Communication aids: context-specific audio/video clips Date arithmetic tools (EDD and Referral) Functionality features Hindi, menu-driven, with audio prompt Seamless integration of guided interactions and recording of data Synchronized between ASHA, AWW and ANM, LS Convergence capability between MoHFW and MWCD at gross root level All data uploaded when connected sync with MCTS feasible Real-time supervisory review module Application for ANM and LS ANM Vaccination Planner for VHND Drill down to case level, helps supervisors to monitor Basic phones (J2ME) Smart phones (Android) Phones Simple and easy to use interface design for low-literate frontline workers 7

8 Results (1/3) Increase in home visits by CHWs On average, treatment area beneficiaries were significantly more likely than those in control areas to report receiving more home visit by CHWs during pregnancy and after child birth 73% 60% 52% 42% 39% 43% 36% 45% 27% 29% Atleast two home visits in final trimester** Home visit within 24 hours of delivery Home visit within 1 week of delivery*** Complimentary feeing home visit (child 5-11 months)** Family planning home visit Control Treatment (regression adjusted) Treatment means are adjusted using ordinary least squares regressions that control for study design effects, demographic characteristics, and subcenter-level baseline means of the outcome (when available). */**/*** Significantly different from zero at the.10/.05/.01 level, two-tailed test, adjusting for clustering at the subcenter level. 8

9 Results (2/3) Impact on quality of home visits by CHWs Relative to beneficiaries living in control areas, those in treatment areas were significantly more likely to receive advice from CHWs on topics related to breastfeeding and nutrition Indicators Control mean Adj. treatment mean Adjusted difference p-value Advice provided by CHW Advice on exclusive breastfeeding * Advised to start feeding at age 6 months *** Advice on types of food ** Advice on times to feed *** Advised on quantity of food using katori * Advised to feed from separate bowl ** Asha or AWW gave phone number of ambulance Advice on skin-to-skin care Home visit by ASHA/AWW about FP Use of Mobile Kunji Card during home visit *** Ever used Katori/Spoon during home visit *** Mother s knowledge About Exclusive Breastfeeding *** Initiating Complimentary feeding at age 6 mo Treatment means are adjusted using ordinary least squares regressions that control for study design effects, demographic characteristics, and subcenter-level baseline means of the outcome (when available). */**/*** Significantly different from zero at the.10/.05/.01 level, two-tailed test, adjusting for clustering at the subcenter level. 9

10 Results (3/3) Impact on quality of home visits by CHWs The study found that children 6 11 months old in treatment areas were 9 percentage points more likely to eat solid or semisolid food compared to those in control areas There was also a significant impact on the timely introduction of complementary feeding (at six months) Also, Current use of modern contraceptive methods was 7 percentage points higher 77% 78% 65% 64% 58% 55% 55% 59% 32% 41% Skin-to-skin care * 18% 24% Child (6-11 months) eats solid or semi-solid food * 22% Child (6-11 months) began eating solid food by age of 6 months ** 29% Child (6-11 months) received DPT3 vaccines 43% 32% 29% Child (6-11 months) fully immunized (excep measles) 36% Use of permanent methods of contraception ** Use of temporary method of contraception (ever) ** Use of any modern method of contraception (ever) *** Use of any modern method of contraception (current) ** Control Treatment (regression adjusted) Treatment means are adjusted using ordinary least squares regressions that control for study design effects, demographic characteristics, and subcenter-level baseline means of the outcome (when available). */**/*** Significantly different from zero at the.10/.05/.01 level, two-tailed test, adjusting for clustering at the subcenter level. 10

11 Stories of success Continuum of Care Services (CCS) Working together (AWW & ASHA) Ms. Seema Kumari, AWW, Nariyar, Kahra, Saharsa - received a new pregnancy information from her catchment. She pre-registered the beneficiary details by looking from her Register-1 into CCS. The pre-registered beneficiary details reflected in her counter part Ms. Lalita Devi, ASHA, Nariyar, Kahra, Saharsa s phone. Ms. Lalita Devi went to beneficiary house and completed the registrations with necessary LMP details Ms. Seema Kumari & Ms. Lalita Devi Ms. Lucy Kumari, AWW, Khojraha, Sonbarsa, Saharsa completed the home visit which is nearer to her house and in the Ms. Sabnam Kumari, Khojraha, Sonbarsa, Saharsa s phone the visit has been marked as done automatically. Ms. Sabnam Kumari went to the other due for that day s home visit Ms. Lucy Kumari On Village Health Nutrition Day(VHND), Ms. Munni Kumari, AWW and Ms. Neetu Devi, ASHA Baijnathpur, Saurbazar, Saharsa has the same immunization due list generated automatically in their phones. Ms. Neetu Devi used for mobilizing the beneficiaries from the catchment to VHND site and Ms. Munni Kumari used for punching the data as soon as the service delivery happened on that day Ms. Neetu Devi Verbatim: Ms. Sabnam Kumari CCS is helping us to work together in the catchment to bring progress in our community ~ Sabnam Kumari, ASHA, Khojraha, Sonbarsa, Saharsa 11

12 Lessons learnt (1/2) Despite limited initial familiarity with technology, CHWs were able to learn to use many of the CCS features effectively CHWs experienced some technical and logistical challenges in using the CCS tool, in particular due to limited internet connectivity, which limited synchronization of records CHWs used some features of the ICT-CCS tool more often than others. Tools to register beneficiaries and manage visits were commonly used; videos, checklists, and supervisory tools were less commonly used After 2 years of implementation, CCS led to substantial improvements in CHW-beneficiary interactions Impact observed in the antenatal care domain, some newborn care practices, child nutrition and use of contraception; No impact on other newborn care practices, facility delivery, or immunizations Impact observed despite the fact that some features of the CCS tools were under-utilized In scaling up, focus will be on improving use of all features of the tool, resolving technical issues, and providing sufficient training 12

13 Lessons learnt (2/2) What has perhaps been the most noteworthy learning from this pilot, is the fact that over 50% of the CHWs and supervisors who were part of this pilot, are still using the ICT-CCS tool today (currently in its fourth year of operation), without any supervisory push to do so. The CHWs have seen value in monitoring and scheduling aspects of the tool, which helps make their day-to-day operations efficient (i.e. by replacing tedious, manual registers and cumbersome process of individual follow-ups), and hence continue to use this tool of their own accord. Ms. Bharathi Kumari, AWW, Mokama, Sonbarsa, Saharsa - used the same phone to alert the department about waterlogging areas after the floods and used a न व (hand made boat) and mobile application to deliver post-disaster services. Ms. Bharathi Kumari 13

14 For any further information, please feel free to contact us! Dr. Hemant Shah, Chief of Party, Bihar Technical Support Program, Care India, Bihar 14